The Open-Fracture Patient Evaluation Nationwide (OPEN) study: epidemiology of open fracture care in the UK

Aims Understanding of open fracture management is skewed due to reliance on small-number lower limb, specialist unit reports and large, unfocused registry data collections. To address this, we carried out the Open Fracture Patient Evaluation Nationwide (OPEN) study, and report the demographic details and the initial steps of care for patients admitted with open fractures in the UK. Methods Any patient admitted to hospital with an open fracture between 1 June 2021 and 30 September 2021 was included, excluding phalanges and isolated hand injuries. Institutional information governance approval was obtained at the lead site and all data entered using Research Electronic Data Capture. Demographic details, injury, fracture classification, and patient dispersal were detailed. Results In total, 1,175 patients (median age 47 years (interquartile range (IQR) 29 to 65), 61.0% male (n = 717)) were admitted across 51 sites. A total of 546 patients (47.1%) were employed, 5.4% (n = 63) were diabetic, and 28.8% (n = 335) were smokers. In total, 29.0% of patients (n = 341) had more than one injury and 4.8% (n = 56) had two or more open fractures, while 51.3% of fractures (n = 637) occurred in the lower leg. Fractures sustained in vehicle incidents and collisions are common (38.8%; n = 455) and typically seen in younger patients. A simple fall (35.0%; n = 410) is common in older people. Overall, 69.8% (n = 786) of patients were admitted directly to an orthoplastic centre, 23.0% (n = 259) were transferred to an orthoplastic centre after initial management elsewhere, and 7.2% were managed outwith specialist units (n = 81). Conclusion This study describes the epidemiology of open fractures in the UK. For a decade, orthopaedic surgeons have been practicing in a guideline-driven, network system without understanding the patient features, injury characteristics, or dispersal processes of the wider population. This work will inform care pathways as the UK looks to the future of trauma networks and guidelines, and how to optimize care for patients with open fractures

Gender mainstreaming and enlargement: the EU as negligent actor?

In its relations with the ‘near abroad’, and in particular with countries eager to attain membership status, the ability of the EU to adopt a proactive role in international politics has been very evident. Indeed, in the case of Central and East European applicants, the EU has used its position to play the role of mentor, shaping transition processes and policy preferences in order to ensure compatibility with the EU acquis. A notable exception in this case has been the EU’s evolving policy on gender relations. While there has been discussion of the formal, legal requirements of equality Directives, the EU’s declared strategy of gender mainstreaming has been disregarded. This absence represents a lost opportunity – for EU and CEEC officials to explore together the potential of, and impediments to, an effective mainstreaming strategy. This paper outlines the principles of gender mainstreaming, explains why gender issues are important in the context of enlargement and suggests reasons for the failure to adopt a mainstreaming strategy during the pre-enlargement period

A global actor past its peak?

Examining a range of policy areas in which the European Union (EU) acts externally – notably trade, development, climate change and foreign and security policy – this article considers the notion that the years since the mid-2000s have witnessed a decline in EU actorness/effectiveness. In evaluating EU performance, the article employs the interrelated concepts of presence, denoting EU status and influence; opportunity, denoting the external context of EU action; and capability, referring to EU policy processes and instruments, with particular reference to the impact of the 2009 Lisbon Treaty. It is contended that achievement of the increased capability envisaged by the Lisbon Treaty, together with resolution of the Eurozone crisis, with its deleterious effect upon the Union’s presence, would not fully compensate for the loss of opportunity provided by the changing international structure

Movements, Networks, Hierarchies: A Gender Perspective on Global Environmental Governance

Environmental governance may be distinguished from environmental management by the implication that, in the former, some form of participatory process is involved. Here, the focus is upon the potential for women's movements and networks to influence the principles and practices of global environmental governance (GEG). It is contended that, in principle, women are uniquely placed to oppose the dominant norms informing GEG; and that women's participation would, in consequence, be crucial to the achievement of equitable and environmentally sound forms of governance. In practice, however, a number of factors combine to create divisions between women, and hence to impede transnational mobilization by women around environmental issues. This article examines these issues. Copyright (c) 2003 Massachusetts Institute of Technology.

The Fragility Fracture Postoperative Mobilisation multicentre audit : the reality of weightbearing practices following operations for lower limb fragility fractures

Aims The purpose of this study was to determine the weightbearing practice of operatively managed fragility fractures in the setting of publically funded health services in the UK and Ireland. Methods The Fragility Fracture Postoperative Mobilisation (FFPOM) multicentre audit included all patients aged 60 years and older undergoing surgery for a fragility fracture of the lower limb between 1 January 2019 and 30 June 2019, and 1 February 2021 and 14 March 2021. Fractures arising from high-energy transfer trauma, patients with multiple injuries, and those associated with metastatic deposits or infection were excluded. We analyzed this patient cohort to determine adherence to the British Orthopaedic Association Standard, “all surgery in the frail patient should be performed to allow full weight-bearing for activities required for daily living”. Results A total of 19,557 patients (mean age 82 years (SD 9), 16,241 having a hip fracture) were included. Overall, 16,614 patients (85.0%) were instructed to perform weightbearing where required for daily living immediately postoperatively (15,543 (95.7%) hip fracture and 1,071 (32.3%) non-hip fracture patients). The median length of stay was 12.2 days (interquartile range (IQR) 7.9 to 20.0) (12.6 days (IQR 8.2 to 20.4) for hip fracture and 10.3 days (IQR 5.5 to 18.7) for non-hip fracture patients). Conclusion Non-hip fracture patients experienced more postoperative weightbearing restrictions, although they had a shorter hospital stay. Patients sustaining fractures of the shaft and distal femur had a longer median length of stay than demographically similar patients who received hip fracture surgery. We have shown a significant disparity in weightbearing restrictions placed on patients with fragility fractures, despite the publication of a national guideline. Surgeons intentionally restrict postoperative weightbearing in the majority of non-hip fractures, yet are content with unrestricted weightbearing following operations for hip fractures

Restricting 32-128 km horizontal scales hardly affects the MJO in the Superparameterized Community Atmosphere Model v.3.0 but the number of cloud-resolving grid columns constrains vertical mixing

The effects of artificially restricting the 32-128 km horizontal scale regime on MJO dynamics in the Superparameterized Community Atmosphere Model v.3.0 have been explored through reducing the extent of its embedded cloud resolving model (CRM) arrays. Two and four-fold reductions in CRM extent (from 128 to 64 km and 32 km) produce statistical composite MJO signatures with spatial scale, zonal phase speed, and intrinsic wind-convection anomaly structure that are all remarkably similar to the standard SPCAM's MJO. This suggests that the physics of mesoscale convective organization on 32-128 km scales are not critical to MJO dynamics in SPCAM and that reducing CRM extent may be a viable strategy for 400% more computationally efficient analysis of superparameterized MJO dynamics. However several unexpected basic state responses caution that extreme CRM domain reduction can lead to systematic mean state issues in superparameterized models. We hypothesize that an artificial limit on the efficiency of vertical updraft mixing is set by the number of grid columns available for compensating subsidence in the embedded CRM arrays. This can lead to reduced moisture ventilation supporting too much liquid cloud and thus an overly strong cloud shortwave radiative forcing, particularly in regions of deep convection. Key Points Physics of MMF MJO are insensitive to near elimination of meso-beta-scale The efficiency of deep convective mixing in MMFs is limited by CRM extent 4x speedup of superparameterized models possible for MJO analysi